PDF Neonatal haemorrhagic conjunctivitis: a specific sign of ...

[Pages:6]K Chang VYW Cheng

NS Kwong

ORIGINAL ARTICLE

Neonatal haemorrhagic conjunctivitis: a specific sign of chlamydial infection

Key words: Chlamydia infections; Conjunctivitis, acute hemorrhagic; Conjunctivitis, inclusion; Infant, newborn

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Hong Kong Med J 2006;12:27-32

Department of Paediatrics and Adolescent Medicine, Tuen Mun Hospital, Tuen Mun, Hong Kong K Chang, MRCPCH, FHKAM (Paediatrics) VYW Cheng, MRCP, FHKAM (Paediatrics) NS Kwong, MRCP, FHKAM (Paediatrics)

Correspondence to: Dr K Chang (e-mail: changkit@)

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Objective. To review the bacteriological causes and clinical features of acute neonatal conjunctivitis in a local paediatric centre. Design. Retrospective review. Setting. Paediatric unit of a regional hospital, Hong Kong. Patients. All neonates who presented to Tuen Mun Hospital from 1 January 1996 to 31 December 2002 with persistent eye discharge and a positive eye swab culture. Main outcome measures. Clinical features of neonates with chlamydial and non-chlamydial conjunctivitis. Results. Of 90 neonates with positive eye swab or conjunctival scraping cultures, Chlamydia trachomatis was the second most common (n=19, 21%) cause of acute neonatal conjunctivitis after Staphylococcus aureus (n=32, 36%). All of the neonates with chlamydial conjunctivitis were delivered vaginally: two of them had concomitant chlamydial pneumonia. Neisseria gonorrhoeae conjunctivitis was rare (n=1, 1%). None of the mothers of neonates with Chlamydia had any history of sexually transmitted disease. The timing of presentation, gestational age, birth weight, and sex of the neonates did not suggest a risk of chlamydial infection. Nonetheless haemorrhagic eye discharge had a specificity of 100% and positive predictive value of 100% for chlamydial infection. There were no adverse ophthalmological consequences or complications of pyloric stenosis in any neonate following treatment with oral erythromycin. Conclusions. Haemorrhagic eye discharge is a highly specific sign of neonatal chlamydial conjunctivitis. Early and prompt treatment with oral erythromycin is safe and effective.

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Introduction

Neonatal conjunctivitis (ophthalmia neonatorum) is defined as inflammation of the conjunctiva which presents during the first month of life.1 The causes can be septic (bacterial or viral) or aseptic (eg a chemical agent such as topical silver nitrate). Most cases of bacterial and viral conjunctivitis are self-limiting except

Hong Kong Med J Vol 12 No 1 February 2006 27

Chang et al

Chlamydia trachomatis and Neisseria gonorrhoeae that can result in blindness if left untreated.2

The increased take-up of high-quality antenatal care in the West and the use of intrapartum antibiotics to treat a positive high-vaginal swab have led to a dramatic reduction in the incidence of gonococcal conjunctivitis.3,4 Chlamydial infection is nevertheless difficult to identify as it does not grow on routine culture medium. In addition, there is no reliable prophylactic topical agent. Topical eye drops such as silver nitrate effectively prevent gonococcal neonatal conjunctivitis but not chlamydial conjunctivitis.5 It is important to eradicate the micro-organism from both the nasopharynx and the ophthalmic area to prevent recurrence.6 Chlamydia trachomatis is now the most frequent identifiable infectious cause of neonatal conjunctivitis in the United States7 and is a major worldwide health problem. The exact cause of neonatal conjunctivitis cannot generally be identified on clinical grounds alone. The timing of symptom onset8 and a history of maternal sexually transmitted disease9 (STD) may give some clues to the underlying cause but are definitely not diagnostic. Early diagnosis and prompt antibiotic treatment of chlamydial conjunctivitis are important if ocular complications are to be minimised,10 but these remain a challenge for physicians. The clinical characteristics of neonates who had conjunctivitis in our hospital were collated in an attempt to determine the risk factors that may in turn predict the occurrence of chlamydial conjunctivitis.

Patients and methods

The clinical records of all neonates with bacterial conjunctivitis diagnosed by positive eye swab cultures or conjunctival scrapings from 1 January 1996 to 31 December 2002 in Tuen Mun Hospital were reviewed. Cases of clinical conjunctivitis with negative microbiological findings were excluded.

Since the early 1990s, routine practice has determined that all neonates who present with eye discharge undergo a thorough physical examination and full microbiological investigation that includes culture and microscopy for bacteria and C trachomatis. A detailed history is also recorded. A Gram stain is usually performed if a direct smear is received. The conjunctival scraping is usually inoculated at the bedside onto a chocolate agar plate for detection of bacteria and a Sabouraud dextrose agar plate for fungal detection. The chocolate agar plate is incubated at 37OC in the presence of 5% CO2, and the Sabouraud dextrose agar plate at 37OC in ambient air. Direct antigen detection for C trachomatis by immunofluorescence testing using monoclonal antibody is performed if slides are prepared at the bedside. Chlamydial culture is performed for a specimen received in chlamydia transport medium. The shell vial culture method is used. The specimen in chlamydia transport medium is inoculated into a monolayer of McCoy cell line on a circular coverslip in a plastic vial and centrifuged at

35OC to 37OC for 1 hour and then incubated at 37OC in chlamydia growth medium in the presence of 2.5% CO2. After 2 days of incubation, the inoculated cell monolayer is stained with commercially available conjugated monoclonal antibody against C trachomatis to look for the presence of immunofluorescence. If signs and symptoms of systemic upset are present, other investigations including nasopharyngeal aspirate, complete blood picture, blood culture, and chest X-ray are performed.

Broad-spectrum antibiotic eye drops, eg chloramphenicol or gentamicin, are prescribed empirically to those with eye discharge to eradicate common causative organisms (eg Staphylococcus aureus, Escherichia coli), while microbiological culture results are awaited. Systemic antibiotics (intravenous penicillin combined with an aminoglycoside) are prescribed if there is systemic upset. The final antibiotic regimen is dictated by discharge culture and bacterial sensitivity results. Neonates were identified as a definite case of chlamydial conjunctivitis only if C trachomatis was isolated in cell cultures.

Variables entered into the analysis included maturity, sex, growth parameters, clinical features such as presence of periorbital oedema, blood-stained eye discharge and systemic upset, and presence of parental history or symptoms of STDs. Treatment given and progress at follow-up were also noted.

The clinical features and demographic features of neonates with chlamydial and non-chlamydial conjunctivitis were compared using univariate analysis. A P value of less than 0.05 was considered significant. This part of statistical analysis was performed with the Statistical Package for the Social Sciences (Windows version 10.0; SPSS Inc, Chicago [IL], US). All organisms yielded were tabulated in decreasing frequency. CATmaker software (Centre for Evidence-based Medicine, Oxford, UK) was used to calculate the sensitivity, specificity, and positive and negative predictive values for different clinical characteristics.

Results

A total of 105 positive eye swab or conjunctival scraping cultures were identified from 90 neonates. Among these, 19 neonates were diagnosed to have chlamydial conjunctivitis with positive culture results while other bacteria caused the remaining 71 cases.

All neonates with chlamydial conjunctivitis were born at full-term except one (Table 1). All were delivered vaginally and were of an appropriate size for gestational age (growth parameters between 10th and 90th centiles). There were more females than males (58% vs 42%). All chlamydiainfected neonates had purulent eye discharge as the first symptom and the median age at presentation was day 7 of life (range, day 1-18). The purulent eye discharge was blood-stained in six (32%) cases (Fig). Periorbital oedema

28 Hong Kong Med J Vol 12 No 1 February 2006

Neonatal haemorrhagic conjunctivitis

Table 1. Chlamydial and other bacterial conjunctivitis

Characteristic

Maturity (weeks of gestations) QFull-term QPreterm (range) Sex QFemale QMale Growth parameters (centile) Q>90th Q50th-90th Q10th-50th Q ................
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